Feast or Famine: Is there a shortage of EMS personnel? Paul Werfel, MS, NREMT-P, CIC Director, EMT & Paramedic Program Assistant Clinical Professor of Health Science School of Health Technology & Management Assistant Professor of Clinical Emergency Medicine School of Medicine Stony Brook University, NY
For copies of this presentation, please email me at: Paul.Werfel@stonybrook.edu
Shortages, what shortages??
Lets Talk About Research:
What / Who determines what we do in EMS? Tradition / EMS Folklore Product manufacturers Ranking officers Medical directors
What should determine what we do in EMS? Evidenced based reality based upon: Solid research Proven observational experience with the intervention in the specific EMS environment in which you practice
What makes good research? Prospective Controlled Good data Outcomes
Problems #1 Lack of solid EMS research #2 When EMS based research is done and published, it often has a profound effect on what is the practiced. #3 The above can occur whether the research is sound or poorly done. #4 Lack of common terms in the research
EMS Shortage Is there really a nationwide EMS shortage? If we don t know how many paramedics we need how do we know we have a shortage? Is there such a thing as too many EMTs and paramedics??
EMS Employers Struggle with Paramedic Shortages EMS agencies nationwide report problems finding enough qualified paramedics to staff their ambulances and ALS first response programs.
Fire Dept. v. EMS How many of you are in fire departments? Why are fire officers supervising EMS folks? If I were a contractor and 85% of my work was plumbing, why would I have carpenters supervising them?
The medical corollary Higher volume of procedures = higher proficiency PCI and CABG The higher the # of procedures performed by the provider the lower the morbidity and mortality Any difference for prehospital critical care skills?
Examples: Endotracheal Intubation: Cardiothoracic Surgery
Pediatric pre-hospital advanced life support care in an urban setting. Prehosp Emerg Care 2001 The average paramedic will intubate a child once very few years, and place an IO in an infant once a career
D.C. Paramedic Shortage Causes Concern Workers Leaving for Better Pay, Benefits By Del Quentin Wilber Washington Post Staff Writer Saturday, May 7, 2005; Page B03
Ambulance crews piling up overtime A union official worries it's only a matter of time before fatigue causes an accident
EMERGENCY SITUATIOn Dying for a Change The city's paramedic shortage puts residents' lives at risk. by Mike Newall The 911 call came into the fire communications dispatch center at 10:21 a.m. on a recent Sunday. It was a code blue: infant cardiac arrest. "No one knows whether paramedics could've saved her," says Philadelphia paramedic Dave Kearney, who's also a fire union representative. "But without paramedics, any chance of survival went out the window."
The reasons for the perceived EMS provider shortage are many and complex. They are not new--you'll know most of these by now: Salaries, in many places, are too low. Volunteerism- YOU ARE NOT GONNA BE HAPPY EMS working conditions--with long shifts, overtime, heavy lifting, bodily fluids and other assorted unpleasantness--aren't alluring. Education and training requirements are significant and often costly. There's frequently no real defined career path for those wishing to move beyond EMT-P. And too many of EMS's best and brightest leave
Why the burn out?
The paramedic staffing shortage How many are needed? Number per capita? How many per resource? Ambulances only? Fire engines? Squads? Tiered response?
Lets go the research: Brown LH, Owens CF Jr, March JA, Archino EA. Does ambulance crew size affect on-scene time or number of prehospital interventions? Prehospital Disaster Med. 1996 Jul-Sep;11(3):214-7; discussion 217-8. East Carolina University School of Medicine, Department of Emergency Medicine, Greenville, North Carolina 27858, USA. INTRODUCTION: While large cities typically staff ambulances with two emergency medical services (EMS) professionals, some EMS agencies use three people for ambulance crews. The Greenville, North Carolina, EMS agency converted from three-person to two-person EMS crews in July 1993. There are no published reports investigating the best crew size for out-of-hospital emergency care. HYPOTHESIS: Two-person EMS crews perform the same number and types of interventions as three-person EMS crews. Two-person EMS crews do not have longer on-scene times than do three-person EMS crews. METHODS: Data for the two most common advanced life support calls in this system--seizures and chest pains--were collected for the months of June and August 1993. Three-person EMS crews responded to both types of calls in June. In August, twoperson EMS crews responded to seizure calls; two-person EMS crews accompanied by a fire department engine (pumper) with additional manpower responded to chest pain calls. The frequency of specific interventions, number of total interventions, and scene times for the August calls were compared to their historical control groups, the June calls. RESULTS: One hundred twenty-six patient contacts were included in the study. There were no significant differences in total number or types of procedures performed for the two patient groups. Mean on-scene time for patients with seizures was 11.0 +/- 4.2 minutes for three-person crews and 19.4 +/- 8.3 minutes for two-person crews (p < 0.001). Mean on-scene time for patients with chest pain was 13.6 +/- 4.9 minutes for three-person crews, and 15.4 +/- 3.2 minutes for two-person crews assisted by fire department personnel (p > 0.05). CONCLUSION: Two-person EMS crews perform the same number of procedures as do three-person EMS crews. However, without the assistance of additional responders, two-person EMS crews may have statistically significantly longer on-scene times than three-person EMS crews.
How many is too many? Paramedics not always the saviors of cardiac-arrest patients By Robert Davis, USA TODAY
Cities with the highest survival rates, the data suggest, train firefighters and citizens to respond first with defibrillators and CPR, sending in a smaller, closely supervised corps of paramedics minutes later to give advanced care.
Comparison of Responder Models: 2 Medics Advantages: Skill redundancy Checks and balances what do you think Scheduling may be easier in certain systems Multiple ALS skills can be performed simultaneously Learning from senior medics Disadvantages: Cost Poor resource allocation Dilution effect on skills Leadership issues Dominant/submissive Working without a net
Comparison of Responder Models: 1 Medic and 1 EMT Advantages: Good resource allocation Develop stronger EMTs and medics Vacancy issues Skills Transition Disadvantages: Cost Possible care issues Transition Skills:
Should a paramedic be on every fire truck, even though most of the calls are not matters of life or death? Or should paramedics be a smaller, more skilled corps that arrives to take over a few minutes after firefighters who just have basic emergency medical training? Most cities opt for more paramedics, despite the expense and evidence that the approach does not necessarily save more lives.
Fewer paramedics Seattle, Boston and Tulsa represent cities with fewer paramedics. They believe that a paramedic who rides a fire engine to every call doesn't get enough practice providing skilled care because so few calls are real medical emergencies.
These cities put a premium on having no more paramedics than their medical director can closely monitor. The more paramedics you put into the system, the more medics that are doing fewer procedures. There have been no scientific studies showing that having more paramedics saves more lives. But it consistently appears to be what the public and most politicians want
Paramedic deployment 100 paramedics on 50 ambulances OR 100 paramedics on 100 ambulances??
Why the shortage? Lousy pay $$ Long hours Too many calls Too many B(L)S calls No career ladder
Fire-based paramedics Rotational system (engine to ambulance) Career pathway (engine captain, EMS captain, chief, etc)
2 paramedic model: 2 on scene vs 2 on an ambulance What percentage of EMS calls involve unstable patients which require 2 paramedics in the back of the ambulance? Typical scenario is 1 medic drives and 1 provides patient care For those cases where 2 medics are needed both can ride in back with a FF or EMT driving
What is the impact of paramedics? Cardiac ischemia/dysrhythmias Shortness of breath
Summary Do you really have a staffing problem or is it a configuration and deployment problem? Create a career pathway for EMS providers Remove a sense of us vs. them mentality for EMS vs. fire suppression Create a positive work environment Forge political alliances Gather community support Remember the ultimate customer More is not necessarily better